Thursday, July 19, 2012

Texas' decision to reject Medicaid expansion quickens trend toward using justice system as mental health substitute

Grits has been further pondering the implications of recent national health care politics on the criminal justice system, now that Gov. Rick Perry and Lt. Governor David Dewhurst have both said they'll oppose expansion of the state Medicaid program to cover Texans with incomes up to 133% of federal poverty levels, even though the feds would pay 100% of costs for the first three years, and 90% of costs after 2019.

Obviously this means the Texas prison system won't be taking advantage of possible state-budget savings from pawning off prisoner hospital costs on the feds. But the more I consider it, the implications for the justice system from this ill-considered political stance are profound and much more far reaching, particularly as it regards the use of jails and prisons as a substitute for funding a more robust community-based mental health system.

At Monday's House County Affairs hearing, Chairman Garnet Coleman noted the irony in response to testimony by witnesses regarding the effectiveness of Veterans Courts, which are essentially mental-health courts aimed at current and former military members. Citing the example of a mentally ill veteran coming back from Afghanistan who, as a civilian, earned less than 133% of the poverty rate, Coleman noted such a person could essentially gain access to mental health services only by committing a crime.  (The Department of Veterans Affairs provides some services, he noted, but nothing like those needed for someone with a chronic, serious mental illness.) By rejecting Medicaid funds, said Coleman, the state would strip away options for indigent veterans and everybody else below the 133% threshold to access treatment services outside the justice system.

His comments got me thinking: The biggest implication for the criminal justice system from rejecting Medicaid funds really stems from the missed opportunity to attract billions (with a "b") in new funding for mental health services that would be delivered outside the criminal justice system.

This would be huge. When discussing the problems posed by the criminalization of mental illness, there's bipartisan acknowledgement that the justice system isn't the best vehicle for providing mental health services. But it's all we've got for now, the fatalists lament, and if one wants to suggest expanding community-based mental-health services, the first response is always "show me the money." Heck, last session legislators even cut mental-health budgets in prison, much less community-based services. With the opportunity to expand Medicaid services on the table - and the feds paying for ALL of it for the first several years, 90% after 2019 - the money to pay for indigent mental services is now officially available. State leaders only need say "yes."

Without such an influx of community-based mental health funds, indigent mental-health care costs will continue to plague county jails and local emergency rooms. Other testimony at Monday's House County Affairs hearing mentioned that, while the overall Bexar County jail populations is declining (as is happening to various degrees across the state), demand for mental-health beds is the one category that continues to increase, straining capacity. And their experience is a microcosm of what's happening statewide.

The reasons are obvious. Texas has under-invested in mental-health care to the point that the state faces a court order declaring long wait times for forensic hospital beds unconstitutional. Mentally ill inmates in jails cost much more than the per-inmate average and pose unique procedural challenges resulting from the justice system's inability to constructively deal with them. The decision to reject billions in community-based mental health funds for the indigent only exacerbates the problem.

35 comments:

doran said...

Assume the Guv and Lt. Dave were to just say "yes." What entities in the private sector would benefit, in addition to the recipients of mental health services? And by how many dollars a year would they benefit? In other words, maybe Perry and Dewhurst just haven't been given the proper/most effective incentives to say yes.

Alyssa Aguirre said...

Mental health has a habit of being tossed to the side. Too many people don't understand the consequences of leaving psychiatric disorders untreated. The problem is that coverage is too out of reach for some, and unless you can find a low cost clinic that offers psychiatric services, it's too expensive to get without insurance.

I have plans to move to Texas in the next year, and it still makes me a little sad that this is what I have to look forward to.

Vincent van Gogh said...
This comment has been removed by the author.
Nurseypooh said...

Texas prisons already house mentally ill offenders some of who are in there minor charges, some I suspect are being housed there because it's better than them being on the street where their family can't protect them so lets say the local law enforcement gets tired of dealing with them they are a nuisance, the family can't make them take their meds or stay in a facility or group home so they are charged with enough charges to get them locked up for a short while to give the family a little respite and the community. It is sad to say but being in prison is sometimes safer than being on the street if your mentally ill.

Vincent van Gogh said...

It must be a slow news day. Warehousing the mentally ill in the prison system is old news. That practice has been going on since rocks and water. In my time in the system I have seen my share of patients that were in need of mental health services. However, in the majority of cases those patients did not commit the offense they were incarcerated for secondary to their mental health diagnosis. If the patient's diagnosis can not be connected to the crime by cause and effect is that warehousing? It also should come as no surprise that many inmates develop their need for mental heath care services after being imprisoned. There are many situations when the provider does not know which came first.

Mental Heath Care is an important aspect of the care TDCJ inmates are all entitled to by Federal mandate. There are those that would gut this aspect of the health care severely but, the constant focus on the suicide rate for TDCJ inmates prevents that from happening. Whenever, an inmate commits suicide the investigation by OIG is swift and sure. In fact it is assumed that the care system failed the inmate and is responsible for his death until it can be proved otherwise.

Mental health care is important but, not anymore so than any other aspect of care. Perry and his legislature need to realize that the care of prisoners is not something they can under fund. Sooner of later a case of improper treatment will come before a Federal Judge. When that happens they will not believe what happens next even while it's happening. What will they say to voters then, when correctional heath care costs go up 4 or 5 times what it is now.

Anonymous said...

"There are many situations when the provider does not know which came first."

That's not surprising when you have an inmate with 5 previous psychiatric hospitalizations and nobody bothers to get the records. Getting records of prior treatment might be a good way to figure out which came first. But, that might be too much trouble, I guess.

Vincent van Gogh said...

Anon 452

What a great suggestion. Do you recomend that the patient have at least 5 hospitalizations to qualify.

At intake when patients are screened for their medical backgrounds it would be ideal to send for any medical history deemed important but, I'm afraid the system is not now nor has it ever been funded for that kind of an expenditure. If you must make sarcastic suggestions try to keep them based in reality.

Gritsforbreakfast said...

Doran, I think Perry will be hearing LOT from those folks. We're talking about $130 billion over ten years, with TX putting up maybe $16 billion tops, last I saw. Plus, if we don't take it, hospitals doing indigent care still lose a chunk of their Disproportionate Share money and then, believe me, all hell breaks loose.

VVG, not a slow news day: Usually we just complain about the lack of funding for mental health care. That's not news. The news hook is that, at this particular historical juncture, between now and next May, the state has a viable option to do something about it.

Vincent van Gogh said...

Grits,

I hope that something is done about the mentally ill in the Texas prison system and I also hope they see fit to fund the other aspects of medical and dental care as well.

Gritsforbreakfast said...

VVG, it's just that the mental health piece is the aspect of the justice system MAJORLY impacted by Obamacare - the in-prison health services will remain a state liability no matter what.

Anonymous said...

"If you must make sarcastic suggestions try to keep them based in reality."

How much does it cost to send a letter to a state hospital asking for records. Last I checked, Vincent, a stamp was 45 cents. But, I guess that's too much to spend before you messing with a person's meds. You can't effectively treat someone without knowing their history. REALISITICALLY, Vincent, any doctor that treats a patient like I'm talking about without reviewing prior records is guilty of malpractice, at least they would be on the outside.

Vincent, let's be REALISTIC. You and I both know that its not money that prevents this. After all 45 cents for a stamp seem pretty REALISTIC to me.

Vincent van Gogh said...

Good point, I wasn't as aware of that content of your blog as I should of been. It's just that it upsets me both morally and with respct to fiscal responsibility, (pay now or later when the Feds get in the act), that nobody seems to care about this particular set of human beings - patients.

Don't get me wrong the attempted manipulation of the medical department by inmates adds enormously to the cost of their care but, that goes with the territory. For example it is common place for inmates to claim they will harm themselves, (are suicidal), just because they think that being transported to Crisis Management in an emergent manner will keep them from facing a case at the unit they are at. My point is there is a lot of waste in the mental health budget. Probably much more than in an area like primary care. To bad things can't be improved across the board.

Vincent van Gogh said...

Anon 644

Sorry, it takes a lot more than a stamp. There is a good deal of expense involved in the man power necessary to disseminate the information and incorperate it in the EMR, (electronic medical record). That procedure times thousands of patients is not possible financially. Especially at the present time. Right now the funding is so poor there is not enough personnel to do much more than hang on and hope there are not any bad outcomes secondary to under staffing. If this is your goal contact your State Rep and tell him/her how you feel. Or break out your credit card - mine is tapped out.

Anonymous said...

Excuses, Excuses.

Anonymous said...

Vincent, I didn't say you had to do that for every inmate. But, when you have one with a significant history of treatment for mental illness, any competent doctor should insist on reviewing those records. So, apparently you are saying that TDCJ can't afford competent doctors.

Btw, this problem has been raised to the legislature. In fact, a while back there was a nurse on here who allegedly worked on a mental health unit who was very offended when I said they didn't get records. She insisted the got all the records. So, either you or she isn't telling the truth. At that time, Grits mentioned that some people had been trying to address this issue and I sent him a copy of a letter that I had from a Psychologist with TDCJ who told me, in writing, that they did not get these records.

This is the type of thing that will get the federal courts involved. Again, I never said you need to get records on every inmate. That's the same kind of overresponse that seems to be typical with these sorts of things. I say, you need to get records on inmates with significant histories. Your response is that it will be too expensive to get them on all inmates. See the problem there?

As I said, this type of thing is going to help get the federal courts involved. Because, for some of these inmates, you need info on their previous treatment to provide competent treatment.

I just don't buy that its too expensive to request a few records for the inmates where it is really necessary. If the doctors at TDCJ are treating patients like the one I'm talking about without reviewing these records, they are definitely not competent and shouldn't have a medical license. But, I suppose, and maybe you can tell me - maybe they just can't afford competent doctors?

Prison Doc said...

Medical Records. Ah yes...often requested, seldom received, rarely helpful. It takes a lot more than a stamp and good intentions.

(1)You have to have the right form, properly signed, properly witnessed. It has to specify which records and what time interval.

(2) It needs to be sent to the right place. Offenders in TDCJ rarely know the correct name or location of their previous treating
facility, or the name of the physician, all of which are vital facts

(3) The request has to wind its way successfully through the bureaucracies of the prison unit, and usually through Galveston and/or Huntsville. It then has to get to the correct healthcare facility.

(4) Many records are the size of an old fashioned metropolitan phone book, so there likely will be a charge for copying at 25 cents a page and shipping. This has to be paid in advance. No money, no records.

(5) The record then has to make it all the way back through the same channels. It will not be likely that the offender is still at the same unit or that the requesting provider is still involved in the case.

(6) Unless the patient has a straightforward psychiatric diagnosis like schizophrenia or manic-phase bipolar disorder, the record won't be helpful. It will show a melange of antisocial behavior, substance abuse disorder, bad psychiatric care, physician-induced prescription drug overuse, and a whole host of other information that is not helpful.

(7) patients treated in the medicaid system or community health clinics formerly known as MHMR but now called by a variety of euphemistic names, have rarely been helped at all. Often they have worsened under that care. That is not to say that MHMR doesn't help some folks, it's just that all of the treatment failures end up in prison or jail.

I think Texas is right to decline the Medicaid money. On mental health it is wasted--doesn't help. I know that "lack of mental health care" conjures up an vision of poor lunatic inmates languishing naked in a cell, ranting and raving without care. Sorry, but that is not the case. Almost all of these poor souls have problems with living, no good social network, serial substance abuse, personality disorders, or other dreadful problems that are not amenable to mental health care.

Anonymous said...

Prison Doc, I respect your opinion. You make some good comments on here and you seem to care about what you do. But, on this you are way off base:

(2) It needs to be sent to the right place. Offenders in TDCJ rarely know the correct name or location of their previous treating
facility, or the name of the physician, all of which are vital facts

Most of this patients relevant records could have been obtained from 1 state hospital. The offender was perfectly capable of providing this info, if anyone had ever asked her. I was communicating with the Director's office through several letters and in none, did anyone ask for this info.

(4) Many records are the size of an old fashioned metropolitan phone book, so there likely will be a charge for copying at 25 cents a page and shipping. This has to be paid in advance. No money, no records.

A state hospital shouldn't be charging to provide records to another state agency. Furthermore, these records could have been easily obtained from the District Attorney. It seems if they have them they should be required to send them without being asked.

(6) Unless the patient has a straightforward psychiatric diagnosis like schizophrenia or manic-phase bipolar disorder, the record won't be helpful. It will show a melange of antisocial behavior, substance abuse disorder, bad psychiatric care, physician-induced prescription drug overuse, and a whole host of other information that is not helpful.

First, I can't give you all the details here, but believe me, these records would have been helpful. Second, if you think schizophrenia and bi-polar are always straight-forward diagnoses, I assume you are not a psychiatrist. Btw, bipolar was one of her diagnoses.

Anonymous said...

Continued from above

7) patients treated in the medicaid system or community health clinics formerly known as MHMR but now called by a variety of euphemistic names, have rarely been helped at all. Often they have worsened under that care. That is not to say that MHMR doesn't help some folks, it's just that all of the treatment failures end up in prison or jail.

I'll agree with you on this one.

(1)You have to have the right form, properly signed, properly witnessed. It has to specify which records and what time interval.
(3) The request has to wind its way successfully through the bureaucracies of the prison unit, and usually through Galveston and/or Huntsville. It then has to get to the correct healthcare facility.
5) The record then has to make it all the way back through the same channels. It will not be likely that the offender is still at the same unit or that the requesting provider is still involved in the case.

These are nothing but pure bureacratic Bullshit excuses, and, Prison Dcc, I thought you were better than that. Should we accept these as justification for failing to provide competent care?

You say these records are "rarely helpful." If you don't ever get them, how do you know? That again, sounds like a bullshit bureacratic response. In this case, and in many others I'm sure they would be helpful. I am aware of another case involving another inmate, where it was not a mental health issue but just a medical issue, where the inmate was permanently injured in a procedure because the doctor didn't have info about a prior treatment that he should have. So, the "rarely helpful" excuse doesn't fly. In the mental health case I'm talking about, the doctor recently wanted to take her completely off her medication. Anyone, doesn't even have to be a doctor, who knows her history immediately realizes what a bad idea this would be. Fortunately, we were able to change the doctors mind. That would have been simply a crazy thing to do - but without the records, the doc didn't know that. So, YES THESE RECORDS WOULD BE HELPFUL. If she didn't have family that tries to look out for her she probably would have been taken off the meds, just to save a few bucks.

Almost all of these poor souls have problems with living, no good social network, serial substance abuse, personality disorders, or other dreadful problems that are not amenable to mental health care.

In this particular case, none of these apply. This person had good family and social support, no substance abuse, no personality disorder. I suspect that, while your description may fit many mentally ill inmates, there are many others it would not apply to.

No offense, Prison Doc, like I said, from what you've had to contribute on here before, I respect you. But, all you've done here is provide bureaucratic Bullshit excuses and downplayed a serious problem. This will come back to bite TDCJ in the ass one of these days. Unfortunately, this agency can't seem to fix any problem until they are bitten on the posterior.

Anonymous said...

Cotinued from above:

Don't you think, when you have got a person who has several psychiatric hospitalizations, that it is important for a treating psychiatrist to know what meds have been tried before. Many of these meds take some time before their effectiveness can be evaluated. So, the doc at the prison could waste months trying meds that have already been proven to be ineffective with this person. All the while, the patient suffers, because someon was too lazy to fill out a couple of forms. Furthermore, as I said, this person was almost taken off her meds because the doc didn't know anything about her history. This person is in prison for a crime committed while she was in a delusional state. She should be in a hospital instead but that's another story. So, had she not had any family to help, she would have been taken off her meds and would have most likely ended up going through a serious psychotic episode. What would it have costs the prison system to deal with that. Probably would have been cheaper to get the records. Now, how many inmates who didn't have family to intervene has this sort of thing happened to?

Anonymous said...

At the risk of beating a dead horse: In the case I'm talking about, there is simply no good rational reason why they records couldn't be obtained with a simple request sent to the state hospital. Cost 45 cents.

Prison Doc said...

Anonymous, you obviously are intimately concerned about and familiar with several salient details of one particular case; my comments are referring to hundreds of cases encountered over an almost two-decade period.

However, if an offender is well maintained on certain medications, why was that information not provided at prison intake? And if their previous psychiatric medications were so darn effective, why did that person offend in the first place> That is prima facie evidence that the medication was not effective to treat the problem.

You can rail on about how my comments are bureaucratic bullshit. Let me let you in on a little inside secret: once you enter the criminal justice system, EVERYTHING AND EVERY DAY is bureaucratic bullshit from meals to clothing to toilet tissue to uniforms. And no, a 45 cent stamp will not get you valid legally usable copies of medical records any time, anywhere, from any source. Seems like they should but Uncle Sam has sabotaged that seemingly easy task. Dream on.

I wish you and your offender well. We inside the razor wire just try to do the best we can for folks with the limitations we have, which are legion.

Anonymous said...

I am the mistress of getting records where I work; usually it takes several phone calls when they are urgently needed. At other times I have tried to obtain records and get sent back a form that says, "not treated at this facilty during date requested" or no record of this patient with this date of birth. In addition to all that I do I must a) find the exact name of the clinic b) city c) date of service d) if these are VA records, the VA has their own form to be filled out and sent in e) have the offender sign the release of information f) find out what exact name DOB, SSN used when they went for care g)if I am faxing the form call to ensure said fax was received. Now multiply this effort by 3-4 patients a day and it's almost not worth the effort. "have a clerk do this". What clerk? She was reduced in force. "Do without those records". The reason for obtaining such records is usually continuity of care, I hear over and over the patient was just about to have surgery on____ and now here she is in jail.

sigh. it will never end. if only obamano could make it so that all records are available to others on a chip that would be implanted under the skin.

Nurseypooh said...

I agree with prison doc. If you are not behind those wires and involved in the day to day process it is very hard to understand. I understand Anon. has a personal situation affect him directly and understand his frustration. It's just hard to comprehend the day to day workings and the bs, hoops, etc. we have to jump through, all in all most of us are there to help the best we can within our means. We do have sucess stories, good outcomes but of course the press doesn't hear about those stories.

Vincent van Gogh said...

Anon

I understand your frustration as you have a personal emotional stake in this debate. If you have read what I have written you most know my sentiments about the correctional care system. However, many people like me have to work everyday in this system and we are well aware that the level of care is not what it should be in many instances. There is a stigma perceived by the public that if you are a health care worker in the correctional system you must be inept and that is the only place you can work. Why? Because logic tells most people, who would want to work in prison? They're right, it is a horrible environment but, there are plenty of skilled caring people who work everyday and put up with all the incompetent cracks and don't get very many thank you's to do it.

When you say it will take Federal intervention by a judge to change things for the better you're right. At least so far the Governor and the legislature don’t seem to what to do it. Believe me; those of us who work in the prison medical system would like nothing more. At the present time we are dangerously low on staff and haven't had a raise in 4 years. A Federal judge would probably say, "No wonder care is not up to par the first thing that is needed is adequate personnel". I am sorry your daughter is in the prison system. Not a good place to be if you need really need top notch care. But, the truth is, it will take a lot more than a stamp and caring medical staff to fix it. Better funding is what is needed first before anything can even begin to be fixed.

sunshine said...

I offered my copies of my grandsons medical records and was told "No Thank You we have our own file. The fact that he had been in medical an psyc care since he was three didn't seem to matter.

Anonymous said...

Hold the high hopes for now. Any extra money will be going to DPS for their pay raises next session. That is a priority over CJ and mundane mental health issues.

Anonymous said...

prison inmates and the mentally ill are vehicles for moving money. All TX is interested in is where the money moves - not what the money does. the last thing they want is to lose their milk-cow. I think that's where the voting logic comes from. in that light, it makes perfect sense. too bad so many people have to suffer for it, but then, we are just a domesticated herd, are we not?

Anonymous said...

Chip implanted under the skin is not an answer. But of course you give fire to the reason to give gov't another way to move money in. Don't you see? You are not expected to produce results. Just be there and look like you're doing something. Results would screw up the whole system. If you were able to obtain the records, it would be something else they would throw in front of your endeavors. You are part of a dog-and-pony show to move funds - nothing more. TDCJ basically has been operating to keep inmates alive long enough to bring in money. the true number of deaths is probably well hidden. You should walk away and get a real job somewhere else - or else get angry enough to make a difference. You'll have to use your imagination, creativity, and intelligence. It's either that or just take it.

Vincent van Gogh said...

Anon 919

"TDCJ basically has been operating to keep inmates alive long enough to bring in money".

What planet do you live on? That is the most obtuse convoluted piece of reasoning I have read in awhile. Texas spends $7.75 an inmate a day on correctional medical care and the security budget is so small in is impossible to hire and keep officers. Try comparing those budgets to other states and you will see how far down the list Texas is. The prison system is a drain on the state economy that the legislature does not want to fund. You need to call them up and let them know they don't need to worry about it anymore since TDCJ is actually making money.

Every death of an inmate in the TDCJ system is investigated by OIG. All that information is a matter of public record.

sunray's wench said...

Why are medical records not attached to an individuals social security number? Surely that would make them much easier to locate?

Anonymous said...

Prison doc,

DSHS should be your main contact point to get medical records from any state hospital, they are supposed to track any and all hospitalizations thru the Care system. There is no oversight or anyone checking the accuracy of this, but it's better than nothing. Someone from your unit needs to contact the Mental Health and Substance Abuse division of DSHS at 1-866-378-8440. This should be a start to getting something done in regards to getting basic records from a hospital the state is in charge of.
2nd:
As far as mental health records from local MHMR's, TCOOMMI funds local MHMR's with COC liaisons who have access to medical records for the MHMR they work for. There is no charge for records and most can be scanned and emailed. Most offenders(not all) have been seen at some point by a local MHMR, so this is a starting point, not a complete fix. Records should be shared with no need for a signed ROI, Folks in all aspects of the criminal justice system need to be aware of SB 839. Please look it up, it will be extremely helpful in getting records from local mhmrs to TDCJ-ID staff. Here is contact info for the folks at TCOOMMI: They are paid to do this and just because there is no oversight, they shouldn't be given a pass to not do anything.
April Zamora -Director april.zamora@tdcj.state.tx.us (512)465-5100
Bennie Jo Wagner -Assistant Director
BennieJo.Wagner@tdcj.state.tx.us 512-465-5100
They have access to email and phone contacts for all local COC's in the state of Texas. These are people who can and should get you records, free of charge and without any kind of release of information thanks to SB 839(which has been in effect since 2007), ridiculous that the state hasn't made more people who work in TDCJ-ID aware of this..Hopefully this will help you and others.

Grandmom said...

TDCJ likes warehousing the mentally ill, especially on death row. In fact, they even create mental illness where none existed before. This should be a felony. It usually takes less than 3 years for a stressed-out, vulnerable DR inmate, housed on solitary confinement, to go stark raving mad. Then when the crazed inmates act out, they are further punished by putting them on level, taking away all their belongings, commissary, visits, sometimes even toilet paper, and feeding them food a dog wouldn't eat. Some guards like to torment them. They were not sentenced to be tortured AND executed!

Anonymous said...

If things are so bad on death row how do the inmates there get cell phones?

DeathBreath said...

Now, we are dealing with the minds of simpletons hell bent on reducing costs which will ultimately fail. First of all, speaking from nearly 23 years of experience in correctional mental health, I can assure you this is going to result in a federal lawsuit. Prison is the absolute worst place to treat someone with a documented history of serious mental illness. The cost of treating patients in prison is much higher than treating them in the free world.

Why? Well, I could write a book on this subject, but I will hit the major problems. Due to reduced prison & correctional managed care budgets: a) seasoned TDCJ-ID officers & experienced mental health clinicians are leaving in droves; b) staff training specific to officers, medical personnel; & psychiatric clinicians has been significantly reduced over the years; c) deep staff cuts have occurred in prison facilities designed to separate those with substandard intelligence from the general population. I could go on and on, but Texas has never profited from their mistakes. Our GOP leadership has gutted effective programs instead of isolating and resolving areas worthy of review & correction. Yes, there were areas of expenditures that could have been refined & modified.

The buffoons in the Texas legislature & Prison board have created a hostile working environment that continues to worsen.

I am thankful that I am outside of this maelstrom of pervasive incompetence. Those in the Texas legislature are an embodiment of buffoons. I am embarrassed to say I'm from Texas.

Anonymous said...

Pvt Administrative Psych Provider: It is incredibly important that GRITS attempts to bring these issues for discussion. After 30 years in this field, I can not accept that we just give up. I have administered a private, state contracted, residential psychiatric treatment facility for more years than I care to count. It maintains an excellent record of care; it meets or exceeds regulatory guidelines; and yes, even obtains treatment records so that treating psychiatrists can be aware of which meds work best and know past medical history (i.e.contagious diseases). We do so at a 1/3 to a 1/5th of the State Hospital Costs. This is possible for the following reasons:
1. lack of a bureaucracy (small corporation)
2. demanding internal standards
3. efficient, effective personnel management policies.
4. refusal to be a "how can we not do this" provider.
5. and a lack of corporate greed.
I do not say any of this to belittle anything anyone has posted. I merely offer that providing care can be done if there is great effort put forth. Unfortunately, government/State operated facilities can be hamstrung by overregulation, poor management, and bureaucracy.

Unfortunately, our tasks have become harder with the reduction in Medicaid funding; Medicaid managed care quagmires in obtaining medical services and medication payment; and the loss of physicians who will treat Medicaid recipients. We care for the most ill psychiatric patients, who will return to prison or state hospitals without their medication, at a much higher costs. I do not have the answers, but, I can not accept defeat.